Dislocations of the hip, knee, or ankle are painful presentations in the trauma ED that must be managed quickly to avoid morbidity, disability, and even possible amputation. This issue presents an evidence-based approach to:
Quickly assess the dislocation based on the mechanism of injury
Manage fractures often associated with dislocations
Quickly and safely diagnose and treat dangerous knee dislocations
Order diagnostic studies to determine the exact nature of the dislocation: x-rays or CT?
Decide whether to immediately reduce the dislocation, or whether urgent surgical consultation is needed first
Choose the best methods for reduction, based on provider and patient needs
Correctly disposition the patient: do all patients need to be admitted?
Dislocation of the major joints of the lower extremities--hip, knee, and ankle--can occur due to motor-vehicle crashes, falls, and sports injuries. Hip dislocations are the most common, and they require emergent management to prevent avascular necrosis of the femoral head. Knee dislocations are uncommon but potentially dangerous injuries that can result in amputation due to the potential for missed secondary injury, especially if they are reduced spontaneously. Isolated ankle dislocations are relatively rare, as most ankle dislocations involve an associated fracture. This review presents an algorithmic approach to management that ensures that pain relief, imaging, reduction, vascular monitoring, and emergent orthopedic consultation are carried out in a timely fashion.
Case Presentations
A 25-year-old man is brought in by ambulance after being involved in a high-speed motor vehicle crash as an unrestrained driver. He is complaining of right hip pain and lower abdominal pain. During his primary trauma survey, you note that his right leg is shortened and internally rotated. You suspect a native hip dislocation and/or fracture and wonder which diagnostic studies you should obtain and whether you should attempt a reduction before consulting orthopedic surgery.
Later that evening, an elderly woman arrives with right hip pain, unable to ambulate. She states, “I was just bending over to put on my shoes when I felt a ‘pop,’ and then I fell to the ground.” She then informs you that she recently underwent right total hip arthroplasty. You notice her right leg appears internally rotated, adducted, and shortened. You suspect a dislocation of her prosthesis and wonder whether you should involve orthopedics or reduce it yourself and, if reduction is successful, whether she can be discharged home.
19-year-old man arrives by EMS, saying that while he was playing a pick-up game of football, he was tackled and felt a “pop” in his right knee. His friend told EMS that his knee looked like it “bent backwards.” His knee was immobilized by EMS, but it doesn’t look deformed. You are concerned that he may have dislocated and spontaneously reduced his knee and wonder if any diagnostic studies are needed.
A 27-year-old man presents to the ED with right ankle pain and obvious deformity. He has severe pain and cannot stand after landing awkwardly in a hole with his right foot when he jumped down from a tree branch. He is unable to bear weight or move his ankle due to severe pain. He appears to have an ankle dislocation and possible fracture; you wonder which takes priority: reduction or imaging?
Introduction
Lower-extremity dislocations are less common in the emergency department (ED) than shoulder and elbow dislocations, and emergency clinicians' experience with evaluation and reduction techniques is often limited. Nonetheless, these dislocations can be serious because of their association with vascular injury. Rapid assessment and timely reduction can minimize pain and complications, but there are many circumstances when emergent orthopedic consultation is needed and surgical referral required. This issue of Emergency Medicine Practice discusses the mechanism of injury, diagnostic approach, treatment plans, and potential complications of dislocations of the hip, knee, and ankle.
Critical Appraisal of the Literature
A literature search was performed in PubMed, EMBase, Medline®, Allied and Complementary Medicine Database, SportDiscus, and Google Scholar using the search terms hip dislocation, anterior hip dislocation, posterior hip dislocation, knee dislocation, ankle dislocation, talar dislocation, subtalar dislocation, hip reduction, knee reduction, and ankle reduction. A total of 163 articles were found regarding hip dislocations, 187 on knee dislocations, and 167 on ankle dislocations. The Cochrane Database of Systematic Reviews was searched, using the terms hip dislocation, knee dislocation, and ankle dislocation, resulting in 8 articles related primarily to knee dislocations. The American College of Emergency Physicians does not endorse any guidelines related to lower-extremity dislocations.
The majority of the applicable literature for lower-extremity dislocations is found in orthopedic and trauma surgery journals. ED-specific studies are limited, though the approach and initial management is the same, regardless of location or provider. Most of the articles in the literature are case reports, case series, and retrospective reviews; there are no large randomized trials assessing diagnosis or management strategies for lower-extremity dislocations.
References
Evidence-based medicine requires a critical appraisal of the literature based upon study methodology and number of subjects. Not all references are equally robust. The findings of a large, prospective, randomized, and blinded trial should carry more weight than a case report.
To help the reader judge the strength of each reference, pertinent information about the study is included in bold type following the reference, where available. In addition, the most informative references cited in this paper, as determined by the authors, are noted by an asterisk (*) next to the number of the reference.
Epstein HC, Wiss DA. Traumatic anterior dislocation of the hip. Orthopedics. 1985;8(1):130, 132-134. (Review)
Pietrafesa CA, Hoffman JR. Traumatic dislocation of the hip. JAMA. 1983;249(24):3342-3346. (Retrospective study)
* Clegg TE, Roberts CS, Greene JW, et al. Hip dislocations-- epidemiology, treatment, and outcomes. Injury. 2010;41(4):329-334. (Review)
Foulk DM, Mullis BH. Hip dislocation: evaluation and management. J Am Acad Orthop Surg. 2010;18(4):199-209. (Review)
Dreinhofer KE, Schwarzkopf SR, Haas NP, et al. Isolated traumatic dislocation of the hip. Long-term results in 50 patients. J Bone Joint Surg Br. 1994;76(1):6-12. (Retrospective study; 50 patients)
* Hak DJ, Goulet JA. Severity of injuries associated with traumatic hip dislocation as a result of motor vehicle collisions. J Trauma. 1999;47(1):60-63. (Retrospective study; 66 patients)
Tornetta P 3rd, Mostafavi HR. Hip dislocation: current treatment regimens. J Am Acad Orthop Surg. 1997;5(1):27-36. (Review)
Wheeless CR. Wheeless’ Textbook of Orthopaedics presented by Duke Orthopaedics. Data Trace Internet Publishing, LLC; 2014. (Textbook)
Frassica FJ, Sim FH, Staeheli JW, et al. Dislocation of the knee. Clin Orthop Relat Res. 1991(263):200-205. (Retrospective study; 17 patients)
Knutson T, Bothwell J, Durbin R. Evaluation and management of traumatic knee injuries in the emergency department. Emerg Med Clin North Am. 2015;33(2):345-362. (Review)
Brautigan B, Johnson DL. The epidemiology of knee dislocations. Clin Sports Med. 2000;19(3):387-397. (Review)
Harb A, Lincoln D, Michaelson J. The MR dimple sign in irreducible posterolateral knee dislocations. Skeletal Radiol. 2009;38(11):1111-1114. (Case report; 1 patient)
Cush G, Irgit K. Drop foot after knee dislocation: evaluation and treatment. Sports Med Arthrosc. 2011;19(2):139-146. (Review)
Monahan TJ. Management of acute and chronic nerve injuries in the multiple ligament injured knee. Sports Medicine and Arthroscopy Review. 2001;9(3):227-238. (Review)
* Johnson ME, Foster L, DeLee JC. Neurologic and vascular injuries associated with knee ligament injuries. Am J Sports Med. 2008;36(12):2448-2462. (Review)
Georgilas I, Mouzopoulos G. Anterior ankle dislocation without associated fracture: a case with an 11 year follow-up. Acta Orthop Belg. 2008;74(2):266-269. (Case report; 1 patient)
Gogi N, Khan SA, Anwar R. Anterior dislocation of the tibio-talar joint without diastasis or fracture--a case report. Foot Ankle Surg. 2008;14(1):47-49. (Case report; 1 patient)
Rivera F, Bertone C, De Martino M, et al. Pure dislocation of the ankle: three case reports and literature review. Clin Orthop Relat Res. 2001(382):179-184. (Case series; 3 patients)
Lertwanich P, Santanapipatkul P, Harnroonroj T. Closed posteromedial dislocation of the ankle without fracture: a case report. J Med Assoc Thai. 2008;91(7):1137-1140. (Case report; 1 patient)
Mazur JM, Loveless EA, Cummings RJ. Ankle dislocation without fracture in a child. Am J Orthop (Belle Mead NJ). 2007;36(9):E138-E140. (Case report; 1 patient)
Tarantino U, Cannata G, Gasbarra E, et al. Open medial dislocation of the ankle without fracture. J Bone Joint Surg Br. 2008;90(10):1382-1384. (Case report; 1 patient)
Distefano S, Divita G. A case of pure dislocation of the ankle joint. Ital J Orthop Traumatol. 1988;14(1):133-137. (Case report; 1 patient)
Finkemeier C, Engebretsen L, Gannon J. Tibial-talar dislocation without fracture: treatment principles and outcome. Knee Surg Sports Traumatol Arthrosc. 1995;3(1):47-49. (Case report; 1 patient)
Greenbaum MA, Pupp GR. Ankle dislocation without fracture: an unusual case report. J Foot Surg. 1992;31(3):238-240. (Case report; 1 patient)
Melenevsky Y, Mackey RA, Abrahams RB, et al. Talar fractures and dislocations: a radiologist’s guide to timely diagnosis and classification. Radiographics. 2015;35(3):765-779. (Review)
Abu-Laban R, Rose N. Foot and Ankle. In: Marx J, Hockenberg R, Walls R, eds. Rosen’s Emergency Medicine - Concepts and Clinical Practice. 8th ed. Philadelphia, PA: Saunders; 2013:723-750. (Textbook chapter)
Moehring HD, Tan RT, Marder RA, et al. Ankle dislocation. J Orthop Trauma. 1994;8(2):167-172. (Review)
Karampinas PK, Kavroudakis E, Polyzois V, et al. Open talar dislocations without associated fractures. Foot Ankle Surg. 2014;20(2):100-104. (Case series; 9 patients)
* Weston JT, Liu X, Wandtke ME, et al. A systematic review of total dislocation of the talus. Orthop Surg. 2015;7(2):97-101. (Systematic review; 86 patients)
Syed AA, Agarwal M, Dosani A, et al. Medial subtalar dislocation: importance of clinical diagnosis in distinguishing from other dislocations. Eur J Emerg Med. 2003;10(3):232-235. (Review)
Dean DB. Field management of displaced ankle fractures: techniques for successful reduction. Wilderness Environ Med. 2009;20(1):57-60. (Review)
Wood GC, McLauchlan GJ. Outcome assessment in the elderly after total hip arthroplasty. J Arthroplasty. 2006;21(3):398-404. (Randomized controlled trial; 99 patients)
Tabuenca J, Truan JR. Knee injuries in traumatic hip dislocation. Clin Orthop Relat Res. 2000;(377):78-83. (Retrospective study; 187 patients)
* Barnes CJ, Pietrobon R, Higgins LD. Does the pulse examination in patients with traumatic knee dislocation predict a surgical arterial injury? A meta-analysis. J Trauma. 2002;53(6):1109-1114. (Meta-analysis; 7 studies; 284 injuries)
Klimke A, Furin M. Prehospital Immobilization. In: Roberts JR, ed. Roberts and Hedges’ Clinical Procedures in Emergency Medicine. 6th ed. Philadelphia, PA: Elsevier; 2014:893-922. (Textbook chapter)
Gray JL, Cindric M. Management of arterial and venous injuries in the dislocated knee. Sports Med Arthrosc. 2011;19(2):131-138. (Review)
Mills WJ, Barei DP, McNair P. The value of the ankle-brachial index for diagnosing arterial injury after knee dislocation: a prospective study. J Trauma. 2004;56(6):1261-1265. (Prospective study; 38 patients)
* Seroyer ST, Musahl V, Harner CD. Management of the acute knee dislocation: the Pittsburgh experience. Injury. 2008;39(7):710-718. (Review)
Brooks RA, Ribbans WJ. Diagnosis and imaging studies of traumatic hip dislocations in the adult. Clin Orthop Relat Res. 2000(377):15-23. (Review)
Roberts JR, Hedges J. Roberts and Hedges’ Clinical Procedures in Emergency Medicine. 4th ed. Philadelphia, PA: Elsevier; 2004. (Textbook)
Gimber LH, Scalcione LR, Rowan A, et al. Multiligamentous injuries and knee dislocations. Skeletal Radiol. 2015;44(11):1559-1572. (Review)
Klineberg EO, Crites BM, Flinn WR, et al. The role of arteriography in assessing popliteal artery injury in knee dislocations. J Trauma. 2004;56(4):786-790. (Retrospective study; 55 patients)
* Nicandri GT, Chamberlain AM, Wahl CJ. Practical management of knee dislocations: a selective angiography protocol to detect limb-threatening vascular injuries. Clin J Sport Med. 2009;19(2):125-129. (Review)
Jaskulka RA, Fischer G, Fenzl G. Dislocation and fracture-dislocation of the hip. J Bone Joint Surg Br. 1991;73(3):465-469. (Retrospective study; 54 patients)
Hillyard RF, Fox J. Sciatic nerve injuries associated with traumatic posterior hip dislocations. Am J Emerg Med. 2003;21(7):545-548. (Retrospective study; 106 patients)
Eyi YE, Arziman I, Kaldirim U, et al. Fascia iliaca compartment block in the reduction of dislocation of total hip arthroplasty. Am J Emerg Med. 2014;32(9):1139. (Case report; 1 patient)
* Vinson DR, Hoehn CL. Sedation-assisted orthopedic reduction in emergency medicine: the safety and success of a one physician/one nurse model. West J Emerg Med. 2013;14(1):47-54. (Prospective study; 442 patients)
Yang EC, Cornwall R. Initial treatment of traumatic hip dislocations in the adult. Clin Orthop Relat Res. 2000(377):24-31. (Review)
* Frymann SJ, Cumberbatch GL, Stearman AS. Reduction of dislocated hip prosthesis in the emergency department using conscious sedation: a prospective study. Emerg Med J. 2005;22(11):807-809. (Prospective study; 101 patients)
Schafer SJ, Anglen JO. The East Baltimore lift: a simple and effective method for reduction of posterior hip dislocations. J Orthop Trauma. 1999;13(1):56-57. (Prospective study)
Hendey GW, Avila A. The Captain Morgan technique for the reduction of the dislocated hip. Ann Emerg Med. 2011;58(6):536-540. (Prospective study; 77 patients)
Dan M, Phillips A, Simonian M, et al. Rocket launcher: a novel reduction technique for posterior hip dislocations and review of current literature. Emerg Med Australas. 2015;27(3):192-195. (Prospective study; 6 patients)
Boss SE, Mehta A, Maddow C, et al. Critical orthopedic skills and procedures. Emerg Med Clin North Am. 2013;31(1):261-290. (Review)
* Howells NR, Brunton LR, Robinson J, et al. Acute knee dislocation: an evidence based approach to the management of the multiligament injured knee. Injury. 2011;42(11):1198-1204. (Review)
Dedmond BT, Almekinders LC. Operative versus nonoperative treatment of knee dislocations: a meta-analysis. Am J Knee Surg. 2001;14(1):33-38. (Meta-analysis; 206 patients)
Jiang W, Yao J, He Y, et al. The timing of surgical treatment of knee dislocations: a systematic review. Knee Surg Sports Traumatol Arthrosc. 2015;23(10):3108-3113. (Systematic review; 150 patients)
Horn A, Ufberg J. Management of Common Dislocations. In: Roberts JR, ed. Roberts and Hedges’ Clinical Procedures in Emergency Medicine. 6th ed. Philadelphia, PA: Elsevier; 2014:954-998. (Textbook chapter)
Thangarajah T, Giotakis N, Matovu E. Bilateral ankle dislocation without malleolar fracture. J Foot Ankle Surg. 2008;47(5):441-446. (Case report; 1 patient)
Grotz MR, Alpantaki K, Kagda FH, et al. Open tibiotalar dislocation without associated fracture in a 7-year-old girl. Am J Orthop (Belle Mead NJ). 2008;37(6):E116-E118. (Case report; 1 patient)
Kellam P, Ostrum RF. Systematic review and meta-analysis of avascular necrosis and posttraumatic arthritis after traumatic hip dislocation. J Orthop Trauma. 2016;30(1):10-16. (Systematic review and meta-analysis; 1707 patients)
Stewart MJ, Milford LW. Fracture-dislocation of the hip; an end-result study. J Bone Joint Surg Am. 1954;36(A:2):315-342. (Retrospective study)
Yahya MM, Mwipatayi BP, Abbas M, et al. Popliteal artery injury: Royal Perth experience and literature review. ANZ J Surg. 2005;75(10):882-886. (Review)
Meek RM, Allan DB, McPhillips G, et al. Epidemiology of dislocation after total hip arthroplasty. Clin Orthop Relat Res. 2006;447:9-18. (Meta-analysis; 14,314 patients)
Smith T, Davies L, Ingham C, et al. What activities cause hip dislocation? A review of 100 total hip replacement dislocations. Adv Physiother. 2014;14(2):55-60. (Retrospective review; 100 patients)
Woo MS, Kang JS, Moon KH. Outcome of total hip arthroplasty for avascular necrosis of the femoral head in systemic lupus erythematosus. J Arthroplasty. 2014;29(12):2267-2270. (Prospective study; 32 patients)
Dewal H, Maurer SL, Tsai P, et al. Efficacy of abduction bracing in the management of total hip arthroplasty dislocation. J Arthroplasty. 2004;19(6):733-738. (Retrospective review; 149 patients)
Lombardi AV Jr, Mallory TH, Vaughn BK, et al. Dislocation following primary posterior-stabilized total knee arthroplasty. J Arthroplasty. 1993;8(6):633-639. (Case report; 1 patient)
Aderinto J, Gross AW, Rittenhouse B. Non-traumatic anterior dislocation of a total knee replacement associated with neurovascular injury. Ann R Coll Surg Engl. 2009;91(8):658-659. (Case report; 1 patient)
Sillanpää P, Mattila VM, Iivonen T, et al. Incidence and risk factors of acute traumatic primary patellar dislocation. Med Sci Sports Exerc. 2008;40(4):606-611. (Retrospective database study; 72 patients)
Mäenpää H, Lehto MU: Patellar dislocation. The long-term results of nonoperative management in 100 patients. Am J Sports Med. 1997;25(2):213-217. (Retrospective review; 100 patients)
Mayer S, Albright JC, Stoneback JW. Pediatric knee dislocations and physeal fractures about the knee. J Am Acad Orthop Surg. 2015;23(9):571-580. (Review)
Brav EA. Traumatic dislocation of the hip. J Bone Joint Surg Am. 1962;44(6):1115-1134. (Retrospective review; 3 patients)
Hougaard K, Thomsen PB. Traumatic posterior dislocation of the hip--prognostic factors influencing the incidence of avascular necrosis of the femoral head. Arch Orthop Trauma Surg. 1986;106(1):32-35. (Retrospective review; 98 patients)
Points
90% of hip dislocations are posterior; 10% percent are anterior.
Typically, an AP pelvic radiograph is adequate to diagnose a hip dislocation. Judet views are helpful in diagnosing associated fractures.
Traumatic dislocations of the native hip should be reduced within 6 hours to reduce the risk of avascular necrosis and posttraumatic arthritis.
To continue reading, please log in or purchase access.
Lower-extremity dislocations are less common in the emergency department (ED) than shoulder and elbow dislocations, and emergency clinicians’ experience with evaluation and reduction techniques is often limited. Nonetheless, these dislocations can be serious because of their association with vascular injury. This episode discusses the mechanism of injury, diagnostic approach, treatment plans, and potential complications of dislocations of the hip, knee, and ankle.
This episode of EB Medicine’s EMplify podcast is hosted by Jeff Nusbaum, MD, and Nachi Gupta, MD, PhD. This month’s corresponding full-length journal issue of Emergency Medicine Practice was authored by Dr. Caylyne Arnold, Dr. Zane Fayos, Dr. David Bruner, and Dr. Dylan Arnold. It was peer reviewed by Dr. Melissa Leber and Dr. Christopher Tainter.
The validation study of the Bastion Classification (Jacobs 2014) was not designed to correlate class of injury with outcomes such as mortality, transfusion requirements, or definitive amputation level.
The Bastion Classification correlates better in blast injuries resulting in traumatic amputations than in segmental injuries.
Because not all injuries involve complete traumatic amputation of a limb, this classification is supplemented by the suffix “S” to denote a segmental injury, defined as the presence of potentially viable tissue distal to the most proximal injury.
Associated injuries to the intraperitoneal abdomen, genitalia and perineum, pelvic ring, and upper limbs are important in treatment and operative planning, so these are denoted by additional suffixes A through D, respectively.
Prehospital application of a tourniquet can effectively obtain hemorrhage control. The study validating the Bastion Classification (Jacobs 2014) had 98 injuries requiring pneumatic tourniquets out of 179 injuries (55%). A recent study in 2017 by Scerbo et al reported that patients who presented without prehospital tourniquets received more transfusions in the first hour of arrival (55% vs. 34%, P = .02) and had increased mortality from hemorrhagic shock (14% vs. 3%, P = .01).
Why and When to Use, and Next Steps
Why to Use
The Bastion Classification was developed as a classification system to comprehensively describe the injury pattern of lower extremities after blast injuries. It correlates with treatment need, such as the requirement for operative proximal vascular control or amputation level. The criteria are helpful for facilitating communication between clinicians and for operative management.
When to Use
Use the Bastion Classification for patients with lower extremity injuries after explosions resulting in complex blast wounds.
The constellation of injuries may include blunt or crush injuries, traumatic amputations, and compartment syndrome, as well as associated neurologic, thoracic, gastrointestinal, and genitourinary injuries.
Next Steps
Management depends on the injuries diagnosed. Using the Bastion Classification and its suffixes, emergency department physicians and trauma surgeons can anticipate the need for other surgical consultations and the resources required for treatment.
Calculator Review Author
Jennie Kim, MD
Department of Surgery
Maimonides Medical Center, Brooklyn, NY
Travis Polk, MD
Commander, Medical Corps, U.S. Navy
Los Angeles County+USC Medical Center, Los Angeles, CA
Evidence Appraisal
A panel of military surgeons, Jacobs et al, developed the Bastion Classification and performed a prospective validation study with 103 patients who sustained 179 lower limb injuries caused by improvised explosive devices treated at Camp Bastion, Afghanistan, from November 2010 to February 2011.
The primary aim of the proposed classification was to provide a pragmatic, comprehensive, and clinically relevant system to better facilitate the transfer of information. Currently existing lower limb injury classification systems fail to describe the complete injury pattern or correlate with management. The Internal Committee of the Red Cross classification is broad and does not provide information on the severity of injury. The Mangled Extremity Severity Score (MESS), Gustilo and Anderson, and Müller AO classifications do not provide information on injury level. The Müller AO classification also does not take into account soft tissue injury. The secondary aim of the study by Jacobs et al was to facilitate the assessment of interventions. The Bastion Classification did show a predictable association with the level of initial musculoskeletal debridement and/or amputation and the level of vascular control.
The original study was not designed to correlate class of injury with outcomes such as mortality, transfusion requirements, or definitive amputation level, and thus, this information is not provided in the publication nor in the conclusions made.
A study in 2013 by Lundy and Hobbs looked at 67 patients with 117 injured limbs caused by dismounted blast exposure. The authors noted that the Bastion Classification appeared to be predictive of initial musculoskeletal treatment but was less useful in predicting the need for proximal vascular control, especially in the most common Class 3 injuries. The original study by Jacobs et al showed that Class 3 injuries correlated with a higher rate of intra- or extraperitoneal iliac vessel control (23% of 83 Class 3 injured limbs without associated abdominal injuries) compared to the study by Lundy et al that only had 1 patient with a Class 3 injury without associated abdominal injury and 6 (5%) of all injured limbs requiring iliac vessel control. The 2013 study does not comment on correlation of the Bastion Classification to mortality rates.
Upon competion of this article, you should be able to:
Assess different types of lower-extremity joint dislocations based on physical examination and radiographic studies.
Choose the most appropriate methods for reduction of dislocation, based on staff resources and patient needs.
Describe the circumstances when it is necessary to obtain specialist consultation for a lower-extremity dislocation.
Physician CME Information
Date of Original Release: December 1, 2017. Date of most recent review: November 10, 2017. Termination date: December 1, 2020.
Accreditation: EB Medicine is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical education for physicians. This activity has been planned and implemented in accordance with the accreditation requirements and policies of the ACCME.
Credit Designation: EB Medicine designates this enduring material for a maximum of 4 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.
ACEP Accreditation: Emergency Medicine Practice is approved by the American College of Emergency Physicians for 48 hours of ACEP Category I credit per annual subscription.
AAFP Accreditation: This Enduring Material activity, Emergency Medicine Practice, has been reviewed and is acceptable for credit by the American Academy of Family Physicians. Term of approval begins 07/01/2017. Term of approval is for one year from this date. Physicians should claim only the credit commensurate with the extent of their participation in the activity. Approved for 4 AAFP Prescribed credits.
AOA Accreditation: Emergency Medicine Practice is eligible for up to 48 American Osteopathic Association Category 2-A or 2-B credit hours per year.
Specialty CME: Included as part of the 4 credits, this CME activity is eligible for 4 Trauma CME credits, subject to your state and institutional approval.
Needs Assessment: The need for this educational activity was determined by a survey of medical staff, including the editorial board of this publication; review of morbidity and mortality data from the CDC, AHA, NCHS, and ACEP; and evaluation of prior activities for emergency physicians.
Target Audience: This enduring material is designed for emergency medicine physicians, physician assistants, nurse practitioners, and residents.
Goals: Upon completion of this activity, you should be able to: (1) demonstrate medical decision-making based on the strongest clinical evidence; (2) cost-effectively diagnose and treat the most critical presentations; and (3) describe the most common medicolegal pitfalls for each topic covered.
Discussion of Investigational Information: As part of the journal, faculty may be presenting investigational information about pharmaceutical products that is outside Food and Drug Administration–approved labeling. Information presented as part of this activity is intended solely as continuing medical education and is not intended to promote off-label use of any pharmaceutical product.
Faculty Disclosure: It is the policy of EB Medicine to ensure objectivity, balance, independence, transparency, and scientific rigor in all CME-sponsored educational activities. All faculty participating in the planning or implementation of a sponsored activity are expected to disclose to the audience any relevant financial relationships and to assist in resolving any conflict of interest that may arise from the relationship. In compliance with all ACCME Essentials, Standards, and Guidelines, all faculty for this CME activity were asked to complete a full disclosure statement. The information received is as follows: Dr. Arnold, Dr. Fayos, Dr. Bruner, Dr. Arnold, Dr. Leber, Dr. Tainter, Dr. Mishler, Dr. Toscano, and their related parties report no significant financial interest or other relationship with the manufacturer(s) of any commercial product(s) discussed in this educational presentation. Dr. Jagoda made the following disclosures: Consultant, Daiichi Sankyo Inc; Consultant, Pfizer Inc; Consultant, Banyan Biomarkers Inc; Consulting fees, EB Medicine.
Commercial Support: This issue of Emergency Medicine Practice did not receive any commercial support.
Earning Credit: Two Convenient Methods: (1) Go online to www.ebmedicine.net/CME and click on the title of the article. (2) Mail or fax the CME Answer And Evaluation Form (included with your June and December issues) to EB Medicine.
Hardware/Software Requirements: You will need a Macintosh or PC to access the online archived articles and CME testing.
Additional Policies: For additional policies, including our statement of conflict of interest, source of funding, statement of informed consent, and statement of human and animal rights, visit www.ebmedicine.net/policies